Download Informed Consent – Extensor Tendon Repair Surgery Informed

Informed Consent
Extensor Tendon Repair Surgery
©2016 American Society of Plastic Surgeons®. Purchasers of the Informed Consent Resource are given a limited license to modify documents
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Informed Consent – Extensor Tendon Repair Surgery
INSTRUCTIONS
This is an informed-consent document that has been prepared to help inform you about extensor tendon
repair surgery, its risks, as well as alternative treatment(s).
It is important that you read this information carefully and completely. Please initial each page, indicating
that you have read the page and sign the consent for surgery as proposed by your plastic surgeon and
agreed upon by you.
GENERAL INFORMATION
Extensor tendons connect muscles in the forearm to structures within the hand and fingers. Tendons
allow the contractile force of forearm muscles to be used for movement in the wrist, hand, and fingers.
Injuries to extensor tendons may severely affect function of the hand due to disruption of the muscletendon unit(s).
Injuries to extensor tendons may occur from cuts, crush injuries, sprains, or in rare cases, without
apparent injury. Extensor tendons can be injured by attritional changes in arthritic conditions. Once
severed, it is unlikely that a tendon can heal without surgical repair. Partially cut tendons may or may not
require repair, depending on the extent of damage. Restoration of hand function after injury to extensor
tendons requires surgery, aftercare, and supervised hand rehabilitation in order to obtain the best results.
Hand injuries severe enough to cut extensor tendons may damage other vital structures within the
forearm, hand, and fingers such as blood vessels, nerves, bones and soft tissues important to normal
hand function. These structures may require repair in addition to the extensor tendon(s). Damage to
these structures may be only discovered at the time of surgery.
ALTERNATIVE TREATMENTS
Alternative treatment consists of not undergoing surgery for tendon repair. There is the possibility of loss
of function if cut tendons are not repaired. Risks and potential complications are associated with
alternative forms of surgical treatment.
INHERENT RISKS OF EXTENSOR TENDON REPAIR SURGERY
Every surgical procedure involves a certain amount of risk, and it is important that you understand these
risks and the possible complications associated with them. In addition, every procedure has limitations.
An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential
benefit. Although the majority of patients do not experience these complications, you should discuss
each of them with your plastic surgeon to make sure you understand all possible consequences of
extensor tendon repair surgery.
SPECIFIC RISKS OF EXTENSOR TENDON REPAIR SURGERY
Tendon Scarring:
Injuries to extensor tendons also affect other structures necessary for proper tendon function. Scarring
can occur within the tendon repair itself or in nearby structures to prevent the return of normal tendon
function. Additional surgery may not be successful in freeing the tendon from scar tissue which prevents
motion. When tendon scarring occurs, other structures such as joints may lose normal motion.
Complex Regional Pain Syndrome (CRPS):
Infrequently, patients may experience chronic regional pain syndrome of the affected finger or the whole
hand and upper extremity after the injury. This is an unusual reaction to trauma and results in pain,
swelling, stiffness and increased sensitivity in the hand and must be treated with special medication and
intense therapy.
Page 1 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
Change in Skin Sensation:
A diminished (or loss of) skin sensitivity in the finger, hand or forearm may occur and not totally resolve after
extensor tendon repair.
Failure of Tendon Repair:
Sutures are used to hold the tendon repair together until it has healed and has enough strength for
function. It is possible to break the sutures or tear apart the tendon repair. Breakage of tendon repairs is
a serious problem. If this occurs, additional surgery would be necessary to secondarily repair the tendon.
It is important that you follow all post-operative instructions concerning protecting the tendon repair from
damage.
Inability to Restore Function:
Hand and forearm injuries often involve more than just a cut tendon. Not all damaged structures can be
surgically repaired. Injuries to other soft tissues and bone may prevent adequate tendon function despite
a successful tendon repair. Loss of soft tissues in the finger or hand may require other reconstructive
surgical operations. Some hand injuries may be so severe that there is no reasonable expectation of
return of function. Complications involving other parts of the hand and forearm may occur after hand
injury.
Damage to Associated Structures:
Structures such as nerves, blood vessels, bones and soft tissues may be damaged during surgery. The
potential for this to occur varies with the type of surgical technique utilized. Additional surgery may be
necessary should this problem occur. Injury to associated structures may be temporary or permanent.
Additional Incisions Necessary:
Cut tendons may retract. It may be necessary to extend the original wound where the tendon was cut or
make new incisions to retrieve the retracted tendon(s).
GENERAL RISKS OF SURGERY
Healing Issues:
Certain medical conditions, dietary supplements and medications may delay and interfere with healing.
Patients with massive weight loss may have a healing delay that could result in the incisions coming
apart, infection, and tissue changes resulting in the need for additional medical care, surgery, and
prolonged hospitalizations. Patients with diabetes or those taking medications such as steroids on an
extended basis may have prolonged healing issues. Smoking will cause a delay in the healing process,
often resulting in the need for additional surgery. There are general risks associated with healing such as
swelling, bleeding, possibility of additional surgery, prolonged recovery, color changes, shape changes,
infection, not meeting patient goals and expectations, and added expense to the patient. There may also
be a longer recovery due to the length of surgery and anesthesia. There are nerve endings that may
become involved with healing scars from extremity surgery. While there may not be a major nerve injury,
the small nerve endings during the healing period may become too active producing a painful or
oversensitive area due to the small sensory nerves involved with scar tissue. Often, massage and early
non-surgical intervention resolves this. It is important to discuss post-surgical pain with your surgeon.
Bleeding:
It is possible, though unusual, to experience a bleeding episode during or after surgery. Should postoperative bleeding occur, it may require emergency treatment to drain accumulated blood or you may
require a blood transfusion, though such occurrences are rare. The collection of blood that can occur
under your skin following surgery is referred to as a hematoma. Increased activity too soon after surgery
can lead to increased chance of bleeding and additional surgery. It is important to follow postoperative
instructions and limit exercise and strenuous activity for the instructed time. Non-prescription “herbs” and
dietary supplements can increase the risk of surgical bleeding. Hematoma can occur at any time, usually
Page 2 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
in the first three weeks following injury to the operative area. If blood transfusions are necessary to treat
blood loss, there is the risk of blood-related infections such as hepatitis and HIV (AIDS). Your surgeon
may provide medications after your surgery to prevent blood clots. Medications that are used to prevent
blood clots in veins can produce bleeding and decreased blood platelets.
Infection:
Infection, although uncommon, can occur after surgery. Should an infection occur, additional treatment
including antibiotics, hospitalization, or additional surgery may be necessary. It is important to tell your
surgeon of any other infections, such as a history of MRSA infections, an open wound, recent upper
respiratory infection/ pneumonia, ingrown toenail, insect bite, tooth abscess, or urinary tract infection.
Infections in other parts of the body, may lead to an infection in the operated area. Post-operative
infections often result in more extensive scarring and predispose to revision surgery.
IIeus:
The return of bowel function following surgery is important. An ileus are disruptions in bowel function
caused by the failure of peristalsis or hypomobility of your bowels/ gut resulting in a lack of defecation and
possibly repeated vomiting. Anesthetics and medications like pain medications given to you at the time of
surgery can contribute to the development of an ileus in the post-operative period. An ileus can result in
abdominal distention, vomiting, inability to absorb oral medications and possibly hospitalization. Repeated
vomiting could result in an aspiration pneumonia and respiratory failure. It can be essential to have
regular bowel function after your surgery.
Scarring:
All surgery leaves scars, some more visible than others. Although good wound healing after a surgical
procedure is expected, this surgery will result in long, prominent scars that are permanent. Abnormal
scars may occur within the skin and deeper tissues. Scars may be unattractive and of different color than
the surrounding skin tone. Scar appearance may also vary within the same scar. Scars may be
asymmetrical (appear different on the right and left side of the body). There is the possibility of visible
marks in the skin from sutures. These scars may become raised, red, or discolored in the first few
weeks/months, but usually settle down over time. However, some patients are prone to “hypertrophic” or
“keloid” scars i.e. prominent, raised, red scars that do not settle. Further treatments with medications
and/or surgery may be required.
Firmness:
Excessive firmness can occur after surgery due to internal scarring.
predictable. Additional treatment including surgery may be necessary.
The occurrence of this is not
Skin Sensitivity:
Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur after surgery.
Usually this resolves during healing, but in rare situations it may be chronic.
Major Wound Separation:
Wounds may separate after surgery. Should this occur, additional treatment including surgery may be
necessary.
Sutures:
Most surgical techniques use deep sutures. You may notice these sutures after your surgery. Sutures
may spontaneously poke through the skin, become visible or produce irritation that requires suture
removal.
Damage to Deeper Structures:
There is the potential for injury to deeper structures including nerves, blood vessels, lymphatics, muscles,
and bone or joint structures during any surgical procedure. The potential for this to occur varies
Page 3 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
according to the type of procedure being performed. Injury to deeper structures may be temporary or
permanent.
Fat Necrosis:
Fatty tissue found deep to the skin might die. This may produce areas of firmness under the skin.
Additional surgery to remove areas of fat necrosis may be necessary. There is the possibility of contour
irregularities in the skin that may result from fat necrosis.
Surgical Anesthesia:
Both local and general anesthesia involves risk. There is the possibility of complications, injury, and even
death from all forms of surgical anesthesia or sedation.
Shock:
In rare circumstances, your surgical procedure can cause severe trauma, particularly when multiple or
extensive procedures are performed. Although serious complications are infrequent, infections or
excessive fluid loss can lead to severe illness and even death. If surgical shock occurs, hospitalization
and additional treatment would be necessary.
Pain:
You will experience pain after your surgery. Pain of varying intensity and duration may occur and persist
after surgery. If you are a chronic pain patient followed by a Pain Therapy Practitioner, you may be asked to
see this practitioner preoperatively to assist you in the management of your pain disorder in the postoperative period. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue or
due to tissue stretching.
There are nerve endings that may become involved with healing scars from surgery. While there may not
be a major nerve injury, the small nerve endings during the healing period may become too active
producing a painful or oversensitive area due to the small sensory nerve involved with scar tissue. Often,
massage and early non-surgical intervention resolves this. It is important to discuss post-surgical pain
with your surgeon.
Cardiac and Pulmonary Complications:
Pulmonary complications may occur secondary to blood clots (pulmonary emboli), fat deposits (fat
emboli), pneumonia, or partial collapse of the lungs after general anesthesia. Pulmonary emboli can be
life-threatening or fatal in some circumstances. Inactivity and other conditions may increase the
incidence of blood clots traveling to the lungs causing a major blood clot that may result in death. It is
important to discuss with your physician any past history of swelling in your legs or blood clots that may
contribute to this condition. Cardiac complications are a risk with any surgery and anesthesia, even in
patients without symptoms. If you experience shortness of breath, chest pains, or unusual heart beats,
seek medical attention immediately. Should any of these complications occur, you may require
hospitalization and additional treatment.
Venous Thrombosis (Clot) and Sequelae:
Thrombosed veins, which resemble cords, occasionally develop in the area of the breast or around IV
sites, and usually resolve without medical or surgical treatment. It is important to discuss with your
surgeon any birth control pills you are taking. Certain high estrogen pills may increase your risk of
thrombosed veins. Personal history of bleeding and clotting problems may also increase your risk of
thrombosed veins.
Allergic Reactions:
In rare cases, local allergies to tape, suture material and glues, blood products, topical preparations or
injected agents have been reported. Serious systemic reactions including shock (anaphylaxis) may occur
in response to drugs used during surgery and prescription medicines. Allergic reactions may require
additional treatment. It is important to notify your physician of any previous allergic reactions.
Page 4 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
Drug Reactions:
Unexpected drug allergies, lack of proper response to medication, or illness caused by the prescribed
drug are possibilities. It is important for you to inform your physician of any problems you have had with
any medication or allergies to medication, prescribed or over the counter, as well as medications you now
regularly take. Provide your surgeon with a list of medications and supplements you are currently taking.
Surgical Wetting Solutions:
There is the possibility that large volumes of fluid containing dilute local anesthetic drugs and epinephrine
that is injected into fatty deposits during surgery may contribute to fluid overload or systemic reaction to
these medications. Additional treatment including hospitalization may be necessary.
Fat/Air Embolism:
In rare cases, fat particles or air can enter the vascular system and can travel to the heart, lungs or brain.
This can result in significant complications including death.
Persistent Swelling (Lymphedema):
Persistent swelling can occur following surgery.
Unsatisfactory Result:
Although good results are expected, there is no guarantee or warranty expressed or implied, regarding
the results that may be obtained. The body is not symmetric and almost everyone has some degree of
unevenness which may not be recognized in advance. One side of the face may be slightly larger, one
side of the face droopier. The breast and trunk area exhibits the same possibilities. Many of such issues
cannot be fully corrected with surgery. The more realistic your expectations as to results, the better your
results will appear to you. Some patients never achieve their desired goals or results, at no fault of the
surgeon or surgery. You may be disappointed with the results of surgery. Asymmetry, unanticipated
shape and size, loss of function, wound disruption, poor healing, and loss of sensation may occur after
surgery. Size may be incorrect. Unsatisfactory surgical scar location or appearance may occur. It may be
necessary to perform additional surgery to improve your results. Unsatisfactory results may NOT improve
with each additional treatment.
ADDITIONAL ADVISORIES
Medications and Herbal Dietary Supplements:
There are potential adverse reactions that occur as the result of taking over-the-counter, herbal, and/or
prescription medications. Aspirin and medications that contain aspirin interfere with normal platelet
function, and therefore may contribute to more bleeding issues. If you have a medical condition (such as
heart arrhythmia, heart stent, blood vessels with blockages, or blood clots) and are taking medications to
thin your blood and prevent clotting such as Plavix, Warfarin, Coumadin, Xarelto, Effient or Pradaxa,
discuss management of these medications around the time of surgery with your plastic surgeon. Your
plastic surgeon may sometimes coordinate a plan for these medications with the doctor that prescribed
them for your medical condition. If you have been prescribed drugs for a medical condition, do not stop
them without discussing it first with your plastic surgeon. Stopping these medications abruptly may result
in a heart attack, stroke, or death. Be sure to check with your physician about any drug interactions that
may exist with medications which you are already taking. If you have an adverse reaction, stop the drugs
immediately and call your plastic surgeon for further instructions. If the reaction is severe, go immediately
to the nearest emergency room.
When taking the prescribed pain medications after surgery, realize that they can affect your thought
process and coordination. Do not drive, do not operate complex equipment, do not make any important
decisions and do not drink any alcohol while taking these medications. Be sure to take your prescribed
Page 5 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
medication only as directed.
Sun Exposure – Direct or Tanning Salon:
The effects of the sun are damaging to the skin. Exposing the treated areas to sun may result in
increased scarring, color changes, and poor healing. Patients who tan, either outdoors or in a salon,
should inform their surgeon and either delay treatment, or avoid tanning until the surgeon says it is safe to
resume. The damaging effect of sun exposure occurs even with the use of sun block or clothing
coverage.
Travel Plans:
Any surgery holds the risk of complications that may delay healing and your return to normal life. Please
let the surgeon know of any travel plans, important commitments already scheduled or planned, or time
demands that are important to you, so that appropriate timing of surgery can occur. There are no
guarantees that you will be able to resume all activities in the desired time frame. Allow at least 10-14
days to travel via airplane. Medications may be required should you have a long flight/ trip to prevent
DVT/ PE in the immediate post-operative period.
Long-Term Results:
Subsequent alterations in the appearance of your body may occur as the result of aging, sun exposure,
weight loss, weight gain, pregnancy, menopause or other circumstances not related to your surgery.
Interference with Sentinel Lymph Node Mapping Procedures:
Breast surgery procedures that involve cutting through breast tissue, similar to a breast biopsy, can
potentially interfere with diagnostic procedures to determine lymph node drainage of breast tissue to stage
breast cancer.
Body-Piercing:
Individuals who currently wear body-piercing jewelry in the surgical region are advised that an infection
could develop from this activity. Body-piercing jewelry should be removed prior to your surgical
procedure.
Nails:
To monitor your vital signs during surgery, your anesthesia provider may require access to your finger
nails for monitoring. Make sure to have at least two finger nails free of nail polish or acrylic nails on the
date of your surgery.
Jewelry:
Jewelry should not be brought with you at the time of your surgical procedure. Items such as earrings,
wedding rings, necklaces, etc. should be removed and placed in a safe place. Do not bring your jewelry
with you for your surgery.
Female Patient Information:
It is important to inform your plastic surgeon if you use birth control pills, estrogen replacement, or if you
suspect you may be pregnant. Many medications including antibiotics may neutralize the preventive
effect of birth control pills, allowing for conception and pregnancy.
Intimate Relations After Surgery:
Surgery involves coagulating of blood vessels and increased activity of any kind may open these vessels
leading to a bleed, or hematoma. Activity that increases your pulse or heart rate may cause additional
bruising, swelling, and the need for return to surgery to control bleeding. It is wise to refrain from intimate
physical activities until your physician states it is safe.
Mental Health Disorders and Elective Surgery:
Page 6 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
It is important that all patients seeking to undergo elective surgery have realistic expectations that focus
on improvement rather than perfection. Complications or less than satisfactory results are sometimes
unavoidable, may require additional surgery and often are stressful. Please openly discuss with your
surgeon, prior to surgery, any history that you may have of significant emotional depression or mental
health disorders. Although many individuals may benefit psychologically from the results of elective
surgery, effects on mental health cannot be accurately predicted.
ADDITIONAL SURGERY NECESSARY (Re-Operations):
There are many variable conditions that may influence the long-term result of surgery. It is unknown how
your tissue may respond or how wound healing will occur after surgery. Secondary surgery may be
necessary to perform additional tightening or repositioning of body structures. Should complications
occur, additional surgery or other treatments may be necessary. Even though risks and complications
occur infrequently, the risks cited are associated with this surgery. Other complications and risks can
occur but are less common. The practice of medicine and surgery is not an exact science. Although
good results are expected, there is no guarantee or warranty expressed or implied, on the results that
may be obtained. In some situations, it may not be possible to achieve optimal results with a single
surgical procedure. You and your surgeon will discuss the options available should additional surgery be
advised. There may be additional costs and expenses for such additional procedures, including surgical
fees, facility and anesthesia fees, pathology and lab testing.
PATIENT COMPLIANCE:
Follow all physician instructions carefully; this is essential for the success of your outcome. It is important
that the surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the
time of healing. Personal and vocational activity needs to be restricted. Protective dressings and drains
should not be removed unless instructed by your plastic surgeon. Successful post-operative function
depends on both surgery and subsequent care. Physical activity that increases your pulse or heart rate
may cause bleeding, bruising, swelling, fluid accumulation and the need for return to surgery. It is
important that you participate in follow-up care, return for aftercare, and promote your recovery after
surgery.
ATTESTATIONS
Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray):
Patients who are currently smoking or use tobacco or nicotine products (patch, gum, or nasal spray) are
at a greater risk for significant surgical complications of skin loss and delayed healing and additional
scarring. Individuals exposed to second-hand smoke are also at potential risk for similar complications
attributable to nicotine exposure. Additionally, smoking may have a significant negative effect on
anesthesia and recovery from anesthesia, with coughing and possibly increased bleeding. Individuals
who are not exposed to tobacco smoke or nicotine-containing products have a significantly lower risk of
these type of complications. Please indicate your current status regarding these items below:
__ I am a non-smoker and do not use nicotine products. I understand the potential risk of second-hand
smoke exposure causing surgical complications.
__ I am a smoker or use tobacco / nicotine products. I understand the risk of surgical complications due
to smoking or use of nicotine products.
__ I have smoked and stopped approximately _________ ago. I understand I may still have the effects
and therefore risks from smoking in my system, if not enough time has lapsed.
___ I have been advised to stop smoking immediately and have been informed of the risks, benefits,
expectations and alternatives to my surgery if I continue smoking.
Page 7 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
It is important to refrain from smoking at least 6 weeks before surgery and until your physician states it is
safe to return, if desired. I acknowledge that I will inform my physician if I continue to smoke within this
time frame, and understand that for my safety, the surgery, if possible, may be delayed.
Smoking may have such a negative effect on your surgery that a urine or blood test just before surgery
may be done which will prove the presence of Nicotine. If positive, your surgery may be cancelled and
your surgery, scheduling fee, and other prepaid amounts may be forfeited. Honestly disclose smoking to
your surgeon.
Sleep Apnea / CPAP:
Individuals who have breathing disorders such as “Obstructive Sleep Apnea” and who may rely upon
CPAP devices (continuous positive airway pressure) or utilize nighttime oxygen are advised that they are
at a substantive risk for respiratory arrest and death when they take narcotic pain medications following
surgery. This is an important consideration when evaluating the safety of surgical procedures in terms of
very serious complications, including death, that relate to pre-existing medical conditions. Surgery may be
considered only with monitoring afterwards in a hospital setting in order to reduce risk of potential
respiratory complications and to safely manage pain following surgery.
Please consider the following symptoms of sleep apnea:
___ I am frequently tired upon waking and throughout the day
___ I have trouble staying asleep at night
___ I have been told that I snore or stop breathing during sleep
___ I wake up throughout the night or constantly turn from side to side
___ I have been told that my legs or arms jerk while I’m sleeping
___ I make abrupt snorting noises during sleep
___ I feel tired or fall asleep during the day
It is important for you to inform and discuss any of the above symptoms that you have experienced with
your surgeon.
DVT/PE Risks and Advisory:
There is a risk of blood clots, Deep Vein Thrombosis (DVT) and Pulmonary Embolus (PE) with every
surgical procedure. It varies with the risk factors below. The higher the risk factors, the greater the risk
and the more involved you must be in both understanding these risks and, when permitted by your
physician, walking and moving your legs. There may also be leg stockings, squeezing active leg devices,
and possibly medicines to help lower your risk.
There are many conditions that may increase or affect risks of clotting. Inform your doctor about any past
or present history of any of the following:
Past History of Blood Clots
Family History of Blood Clots
Birth Control Pills
_______Hormone Stimulating Drugs
Swollen Legs
History of Cancer
Large Dose Vitamins
Varicose Veins
Past Illnesses of the Heart, Liver, Lung, or Gastrointestinal Tract.
_______History of Multiple Spontaneous Abortions or Miscarriages
Page 8 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
I understand the risks relating to DVT/PE and how important it is to comply with therapy as
discussed with my surgeon. The methods of preventative therapy include:
Early ambulation when allowed
Compression devices (SCD/ICD)
____Anticoagulation Protocols when Allowed
For high risk patients, the risks of VTE are still high, even in the setting of appropriate chemoprophylaxis.
If your surgery is elective and you’re a high risk patient, it’s best to consider with not proceeding with such
elective surgery.
COMMUNICATION ACKNOWLEDGEMENT – CONSENT
There are many ways to communicate with you. It is important to keep appointments and let us know if
problems or issues arise. Methods of communicating are by telephone, text, pager, answering service if
available, email, and regular mail. If an emergency arises, keep us alerted to your progress so we may
aid in any necessary treatments. Please do not leave a message after hours or on weekends on the office
answering machine if any urgent or emergent situation exists, as there is a delay in retrieving such
messages. All attempts will be made to preserve your privacy in accordance with HIPAA rules.
Please confirm below all acceptable ways of communicating with you:
____ Telephone
____ Home (
____ Work (
____ Cell (
____ Text
____ Pager – Answering Service if available
____ Email – with up to date email address (
____ Regular Mail and Delivery
-
)
)
)
@
)
DISCLAIMER
Informed-consent documents are used to communicate information about the proposed surgical
treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s),
including no surgery. The informed-consent process attempts to define principles of risk disclosure that
should generally meet the needs of most patients in most circumstances.
However, informed-consent documents should not be considered all-inclusive in defining other methods
of care and risks encountered. Your plastic surgeon may provide you with additional or different
information which is based on all the facts in your particular case and the current state of medical
knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care.
Standards of medical care are determined on the basis of all of the facts involved in an individual case
and are subject to change as scientific knowledge and technology advance and as practice patterns
evolve.
It is important that you read the above information carefully and have all of your
questions answered before signing the consent on the next page.
Page 9 of 10
______ Patient Initials
©2016 American Society of Plastic Surgeons®
This form is for reference purposes only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and
amended to reflect policy requirements of your practice site(s), CMS and Joint Commission requirements, if applicable, and legal requirements of
your individual states. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed
consent for this particular procedure in the jurisdiction of your practice.
Informed Consent – Extensor Tendon Repair Surgery
CONSENT FOR SURGERY / PROCEDURE or TREATMENT
1.
I hereby authorize Dr. Jacob Gerzenshtein and such assistants as may be selected to perform Extensor Tendon
Repair Surgery.
I have received the following information sheet: Extensor Tendon Repair Surgery.
2.
I recognize that during the course of the operation and medical treatment or anesthesia, unforeseen conditions may
necessitate different procedures than those above. I therefore authorize the above physician and assistants or
designees to perform such other procedures that are in the exercise of his or her professional judgment necessary
and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are
not known to my physician at the time the procedure is begun.
3.
I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of
anesthesia involve risk and the possibility of complications, injury, and sometimes death.
4.
I understand what my surgeon can and cannot do, and understand there are no warranties or guarantees, implied or
specific about my outcome. I have had the opportunity to explain my goals and understand which desired outcomes
are realistic and which are not. All of my questions have been answered, and I understand the inherent (specific)
risks to the procedures I seek, as well as those additional risks and complications, benefits, and alternatives.
Understanding all of this, I elect to proceed.
5.
I consent to be photographed or televised before, during, and after the operation(s) or procedure(s) to be performed,
including appropriate portions of my body, for medical, scientific or educational purposes, provided my identity is not
revealed by the pictures.
6.
For purposes of advancing medical education, I consent to the admittance of observers to the operating room.
7.
I consent to the disposal of any tissue, medical devices or body parts that may be removed.
8.
I am aware that there are potential significant risks to my health with the utilization of blood products, and I consent to their
utilization should they be deemed necessary by my surgeon and/or his/her appointees.
9.
I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device
registration, if applicable.
10. I understand that the surgeons’ fees are separate from the anesthesia and hospital charges, and the fees are
agreeable to me. If a secondary procedure is necessary, further expenditure will be required.
11. I realize that not having the operation is an option. I opt out of having this procedure _____.
12. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a. THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
b. THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c. THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-12).
I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patient
Date/Time __________________________ Witness
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______ Patient Initials
©2016 American Society of Plastic Surgeons®